Blossom South Nursing and Rehabilitation Center, 1175 Monroe Ave., has been on the Special Focus Facility Initiative list for 25 months. / Jamie Germano Staff Photographer

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What will it take to fix problems at Blossom South...: Alana Russell, director of the ombudsman program at Lifespan, calls for close monitoring to make sure solutions stick. Video by Patti Singer and Jamie Germano.

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The water was too hot, or it would be so cold that one resident described taking a shower as “polar dipping.”

Outdated insulin was given to another resident, and other insulin vials were open and undated.

As flies buzzed about, food sat on the window ledge of a third resident’s room, close to an unemptied urine container.

Problems with safety and comfort of the environment, drug records, and housekeeping and maintenance had been documented before, but they still were issues when a team from the state Department of Health left Blossom South Nursing and Rehabilitation Center on March 19.

The failure of ownership and management to fix chronic problems has earned Blossom South the distinction of being among the most troubled nursing homes in the nation, according to the Centers for Medicare & Medicaid Services (CMS).

For 25 months, CMS has had the nursing home at 1175 Monroe Ave. in its Special Focus Facility Initiative for homes with a history of serious quality issues. Since then, the Rochester facility has been subject to more intense scrutiny. But it has not shown consistent improvement. According to the rules of the special focus program, continued problems could mean the end of reimbursement for Medicare and Medicaid residents.

The March report detailed 10 repeat violations of state and federal regulations meant to protect the health, safety and care of nursing home residents. The same report documented 15 others — from residents who feared retaliation if they complained about a staff member to the failure to treat residents with dignity to food not being served at the right temperature.

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A Democrat and Chronicle analysis of reports from 18 state inspections at the facility since Feb. 26, 2010, documented 119 violations related directly to residents’ health and safety, such as their rights, quality of life and quality of care. Of those, 33 were repeat violations. The state also documented 48 deficiencies related to the building; 11 were repeat problems.

“This is frustrating,” said Alana Russell, director of the ombudsman program for Lifespan, which provides non-medical services for seniors and their caregivers. “These are human beings. Why are the residents having to endure repeat deficiencies?”

Officials from CMS and the state Department of Health didn’t directly answer that but said facilities are given every chance to right themselves.

Blossom South officials declined an interview. “At this time we are within compliance with all state and federal regulations,” said administrator Christopher Roberts. “We’re just focused on that.”

The 161-bed for-profit nursing home receives taxpayer money in the form of Medicare and Medicaid payments. In 2011, Blossom South reported to the state a total operating revenue of $6.4 million, which included total Medicaid net revenue of approximately $5 million. It listed total operating expenses of $9.1 million.

Only the state can shut down an underperforming nursing home. But CMS can deny Medicaid and Medicare payments to a facility. In each case, officials have to follow a process that can withstand legal challenges.

During the past three years, state inspectors have found violations and fielded complaints at Blossom South far in excess of the state average, according to the Department of Health website. While the state survey team determined that none of the violations in the March inspection placed a resident in immediate jeopardy of injury or death, most of the problems had the potential to do some level of harm and many were part of a pattern. The state also found seven deficiencies — three of them repeated — related to the building itself.

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Most homes undergo an unannounced inspection once every nine to 15 months to recertify the facility’s license and to ensure the facility has fixed any problems found during the inspection. The state also may visit to investigate a complaint. Records showed state inspectors were at Blossom South nine times in 2012.

William Roberson has been CMS associate regional administrator for survey, certification and enforcement in the Northeast Region about as long as Blossom South has been on the special focus list.

“They’ve been in trouble when I arrived and they’re still in trouble. They haven’t gotten out of trouble. We’re getting really tired of it. That’s not an elegant way of putting it.”

He declined to say when or whether it would end payments to Blossom South. “They’re entitled to at least one more survey before I’ll make that decision.”

Diary of 13 months

Kathy Steel’s family didn’t have time or a choice.

Their loved one was being discharged from a hospital and couldn’t go back to assisted living until he could care for himself. He needed skilled nursing.

The hospital social worker said Blossom South was the only facility with a bed for the Medicaid recipient. His stay started in April 2012 and was supposed to be for short-term rehabilitation.

He would be there 13 months.

Steel said concerns began when he moved in. No one brought him anything to drink and he lay in bed, sweating and dehydrated. “From the first day, he didn’t get good care. The very first day.”

Steel started a diary. On the second day, she wrote that when she went to the laundry to put his name on his clothes, the washing machines were broken.

Her mother asked why she was keeping a journal.

“I don’t want to do this,” Steel said. “It took up an immense amount of time. But I have to document this stuff.”

Steel said her loved one (she requested his name and relationship to her not be used) didn’t get proper care. He has a mental illness and requested counseling, and Steel said what was provided was not adequate. He was diabetic, and it took weeks for Steel to get staff to deliver him a bedtime snack to help regulate his blood sugar. She noted that it took months for him to see a dental hygienist. In a 2011 filing to the state, the most recent available, Blossom South reported it provided psychological, dental and optometry services, among others, to residents.

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Steel also said she was unable to speak with a doctor at Blossom South. “I think the most egregious thing is not getting a doctor when we had medical concerns.”

Steel said she filed two complaints with state Department of Health and frequently talked with the ombudsman assigned by Lifespan to Blossom South.

While Steel criticized the care, she said her family member was not in immediate jeopardy and he was not actually harmed, categories the state considers when assessing problems. And

she did encounter caring staff members. “Not everyone is bad. They’re just in bad circumstances. It’s like it’s designed to fail. They can’t keep good staff.”

Steel said that social workers at Blossom South did not tell her that in order to move her loved one back to assisted living, he needed to be assessed on his ability to do everyday activities. She said she learned about the assessments from outside agencies, and when she asked the Blossom staff to do them, it took months. She finally was able to move her loved one in May, 2013.

Steel said advocating for him just about consumed her. “This has been hell for me.”

Staff turnover

Lack of consistent staffing at Blossom South is a frequent complaint, according to Lifespan’s Russell.

She said that over the past 3 ½ years, the ombudsman at Blossom South has recorded at least 11 social workers, nine administrators or acting administrators, and eight nursing directors and four acting directors.

Russell said a transient staff means problems linger. “It’s very paralyzing for us as ombudsmen,” Russell said. “It’s very discouraging for residents.”

Staffing issues also affect the day-to-day, or hour-by-hour, care that residents need.

During the more than weeklong inspection that ended March 19, the state team noted in its report that the facility lacked sufficient 24-hour nursing staff. Residents or family members complained about delays in medication and toileting.

Russell said residents claimed the staff doesn’t respond to call bells in a timely manner. However, she said that unlike daycare settings, there’s no required minimum ratio of staff to residents. Nor, she said, is there a required time in which a bell must be answered.

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Staff members told state inspectors that sometimes there are only three or four certified nursing assistants per unit, making each responsible for 15 residents. “The staff reports it is impossible to take good care of all the residents when you have 15 …,” the March 19 report stated.

Early during the March visit, state inspectors documented that food was served at lukewarm temperatures. A few days later, a resident and a certified nursing assistant said that staff was added because the health department was present.

Todd Hobler is vice president of 1199 SEIU United Healthcare Workers East, which represents close to 150 certified nursing assistants, licensed practical nurses, and housekeeping and dietary staff at Blossom South.

Hobler said that in the past few years, Blossom South generally has had a higher staff turnover than other Rochester nursing homes represented by 1199 SEIU.

“There is a core group that provides good care,” he said. “If they are given the support and resources they need, it will be a much better nursing home than it is.”

Hobler said the combination of Blossom South being a for-profit nursing home and declining Medicaid reimbursement rates creates challenges. The daily rate minimums and maximums were about $150 less than the private pay rate in 2011, according to the report Blossom South submitted to the state.

According to a document filed with the state at the end of 2011, Blossom South was owned by Stephen O’Neill, William Madden and Gerald Wood, each with fractions over 30 percent shares. Yisrael (spelled Yisroel on some state documents) Segal had a 9.9 percent share. A letter from the Department of Health to Segal in September 2012 identifies him as the operator.

O’Neill and Wood are partners in a Nassau County accounting firm, and Madden is with a real estate developer in Westchester County, according to state records. They have co-owned for-profit nursing homes for several years. Various combinations of the four are involved with Blossom Health Care Center and Blossom North Nursing and Rehabilitation Center, according to state and CMS records.

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When reached by phone in early July, Wood said he no longer has anything to do with the facility and that Segal owned it. Segal did not respond to an interview request sent by certified mail. O’Neill and Madden did not respond to messages left at their offices.

Hobler said Segal was trying to make changes. “The record may not reflect a completely new day, but I’m pretty convinced the new operators are trying the best they can,” he said. “Maybe I’m optimistic. We’re hopeful things will change.”

Repeated problems

The state Department of Health shares its inspections with CMS, which pays nursing homes to care for residents eligible for Medicare and Medicaid.

Inspections turn up an average of six or seven problems each time, according to CMS. When a problem is noted, the facility has to submit a plan to correct the deficiency within a specific time. The state has to approve the plan, and the survey team returns to make sure the facility did what it said it would do.

This was the process after the March 19 inspection. On May 17, the state wrote Segal that it accepted the facility’s plan, that Blossom South was in substantial compliance with regulations and had to document that it would stay that way.

Historically, that’s where Blossom South has struggled.

The Democrat and Chronicle analysis showed three deficiencies in three consecutive certification reports — March 2012, September 2012 and March 2013. They related to housekeeping and maintenance; having a licensed pharmacist handle records for controlled drugs; and keeping a safe, functional, sanitary and comfortable environment for residents, staff and the public.

In 1998, CMS started the Special Focus Facility Initiative. Recalcitrant homes — those with more, and more serious problems, and a pattern of severity going back three years — get more frequent and intense scrutiny.

Within 18 to 24 months in the program, CMS lists three possible outcomes: the home graduates; it’s cut off from CMS funding; or it gets more time because it’s improving or may change hands.

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“When they’re on special focus, we’re trying to look at the overall scheme of things of how quickly they are trying to get things corrected,” CMS’ Roberson said. “They may have made progress but not enough to the point where the deficiency was removed. So we would repeat the deficiency.”

Roberson said that when facilities reach 24 months, “it’s time to demonstrate they can perform.”

Blossom South is the only nursing home in Monroe County to be a Special Focus Facility since the CMS began reporting the facilities in 2005, and has been on it twice, the agency reported. The first time was from December 2005 into June 2007, when it was called Arbor Hill Care Center and owned by Anthony Salerno.

Twice in 2005, Arbor Hill was fined a total of $359,125 by CMS for issues related to care. In 2006, Salerno received state approval to sell the operation and the property to O’Neill, Wood and Madden, according to documents from the Department of Health.

Reports on a nursing home’s performance are public record, and owners can’t claim ignorance of previous problems when they buy in, according to Roberson of CMS. “It’d be pretty foolish for them to buy without knowing they are buying and accepting the responsibility for making all of the necessary corrections to bring it into compliance.”

Blossom South was not in the Special Focus Facility program in March 2011, when the state attorney general alleged that two nurses falsified business records.

The Medicaid Fraud Control Unit charged that former director of nursing Cynthia Beckhorn and former nurse manager Sheryl Rowe used the initials of other nurses without permission on medication and treatment records. Beckhorn and Rowe pleaded not guilty and are scheduled to return to court July 29.

Following rules

There apparently is no uniform threshold for when enough is enough.

In June, Blossom South marked 25 months in the Special Focus program. Of the 52 across the country that had not improved, a few had been on the list longer.

“If and when it is determined, after extensive efforts to improve performance and quality of care have occurred, the facility is unable to demonstrate appropriate levels of resident care and safety, a facility closure process may commence,” Jackie Pappalardi, director for the division of residential services for the state Department of Health, wrote in an email to the Democrat and Chronicle.

If a home is shut down, the state works with the facility to move residents to other settings, she also wrote.

The state closed Countryside Care Center in Delaware County last year after it had been on the special focus list for 11 months. The state had not closed any other facilities in the past decade because of care issues.

Roberson said that repeated problems can be the basis for ending a home’s agreement with CMS. But he was deliberately general in talking about whether or when that might apply to Blossom South.

“We take the advice of our counsel. Do we have a case that’s strong enough to win? If we do, I definitely will take that action.”

He said a decision would be based on the severity of any future problems and whether any issues are isolated, a pattern or widespread.

“I want to make it clear to you that we are going to do something if it’s within the scope of reason to do it.”